Deck 37: Perioperative Nursing Care

Question 1

The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly?

A) The patient breathes into the spirometer so that the marker rises slowly.
B) The patient uses the spirometer 5 to 12 times every 1 to 2 hours while awake.
C) The patient seals his lips tightly around the spirometer mouthpiece.
D) The patient should hold each inhaled breath 3 to 5 seconds.

Answer 1

The patient breathes into the spirometer so that the marker rises slowly.

Question 2

The nurse is caring for a preoperative patient who has just received sedation prior to general anesthesia in the OR. What is the priority action of the nurse?

A) Check to make sure that the consent form was signed.
B) Turn off the lights and provide a quiet environment.
C) Raise the side rails on the patient's stretcher.
D) Indicate the surgical site with an indelible marker.

Answer 2

Raise the side rails on the patient's stretcher.

Question 3

The nurse is caring for a patient who has a family history of reactions to general anesthesia. Which medication will the nurse anesthetist have ready as a precautionary measure before the patient's surgery is started?

A) Protamine sulfate
B) Dantrolene sodium (Dantrium)
C) Activated charcoal with sorbitol
D) Folinic acid (Leucovorin)

Answer 3

Dantrolene sodium (Dantrium)

Question 4

The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority Nursing diagnosis for this patient?

A) Risk for imbalanced body temperature
B) Risk for aspiration
C) Risk for perioperative positioning injury
D) Risk for delayed surgical recovery

Question 5

The nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient's care to meet the goals for risk for perioperative positioning injury related to immobilization during surgical procedure?

A) Use adequate assistance to move patient onto the OR table.
B) Watch for early signs of hypovolemia caused by patient's NPO status since midnight.
C) Use therapeutic touch and guided imagery to allay patient's fears of surgery.
D) Pad all bony prominences and avoid hyperextension of extremities.

Question 6

The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first?

A) A patient who is waiting for discharge teaching before going home.
B) A patient who needs to be ambulated for the first time postoperatively.
C) A patient who has not voided since the catheter was removed 8 hours ago.
D) A patient who requires a daily dressing change to the surgical incision.

Question 7

Which action by the nurse best demonstrates accountability in the operating room?

A) Applying warm blankets when the patient reports feeling chilly
B) Holding the patient's hand to allay anxiety before anesthesia is administered
C) Double-checking that the surgical site is clearly marked and visible after draping
D) Using calming speech with a reassuring tone of voice when speaking with the patient

Question 8

The nurse will be caring for a patient who has just arrived on the medical-surgical unit following surgical repair of his fractured right ankle. Which is the priority action of the nurse when the patient arrives on the unit?

A) Instruct the patient how to call for assistance using the call light.
B) Assess the color and warmth of the toes on the patient's right foot.
C) Determine when the patient's next pain medication is due.
D) Check pulse oximetry and obtain a full set of vital signs.

Question 9

The nurse is caring for a patient who will be having surgery. The patient has just signed the consent form for the operation. What does the patient's signature indicate?

A) The patient agrees with the doctor's diagnosis.
B) The patient gives permission for the surgery to be performed.
C) The patient has agreed to pay for any costs not covered by insurance.
D) The patient has been told of all the available treatment options.

Question 10

The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the Nursing diagnosis risk for perioperative positioning injury?

A) Patient will deny numbness or tingling in extremities after surgical procedure.
B) Patient will maintain urine output of at least 30 mL/hr during and after surgery.
C) Patient will maintain elastic skin turgor as well as moist tongue and mucus membranes.
D) Patient will have no emesis and deny nausea following arousal from general anesthesia.

Question 11

The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient's gown over the abdominal incision. The patient states, "I felt something just ripped open." What is the priority action of the nurse?

A) Lift up the patient's gown and assess the incision.
B) Assist the patient to the floor and call for assistance.
C) Return the patient to bed and irrigate the wound with sterile saline.
D) Check the patient's vital signs and pulse oximetry.

Question 12

The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%. What is the best action of the nurse?

A) Assess the airway and administer oxygen.
B) Call for anesthesia to immediately reintubate the patient.
C) Remove the pillow from behind the patient's head.
D) Elevate the head of the patient's bed.

Question 13

The nurse is obtaining preoperative information for a patient who will be having emergency surgery shortly for a ruptured appendix. Which information is crucial for the nurse to assess?

A) All medications that the patient is taking
B) Use of tobacco, alcohol, or recreational drugs
C) Allergies to medications, foods, or other substances
D) Date of last tetanus shot and flu vaccination
E) Insurance coverage and preauthorization requirements
F) Possibility of pregnancy

Question 14

The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery and notes that the patient has many tubes and monitors in place. Which will the nurse assess first?

A) The patient's intravenous lines
B) The patient's urinary catheter
C) The patient's nasogastric tube
D) The patient's endotracheal tube

Question 15

The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and has no intention of getting out of bed. What is the nurse's best response?

A) "It's important to move around so you don't get a blood clot in your leg."
B) "Your doctor ordered that you are to get out of bed at least twice every day."
C) "I understand. You can rest in bed until tomorrow when the pain is better."
D) "I will call the doctor and let him know that you do not want to get up."

Question 16

The nurse is caring for a patient with advanced colon cancer. The patient is to have surgery to relieve a bowel obstruction that has been causing unrelenting vomiting and abdominal pain. What type of surgery will this patient undergo?

A) Palliative
B) Reconstructive
C) Diagnostic
D) Ablative

Question 17

The nurse is caring for a postoperative patient who has a history of COPD. What is the priority Nursing diagnosis for this patient?

A) Ineffective airway clearance
B) Readiness for enhanced knowledge
C) Risk for delayed surgical recovery
D) Activity intolerance

Question 18

After general anesthesia is administered, the patient is carefully placed in the prone position. What is the primary consideration of the nursing staff as the patient is positioned?

A) Making sure that the patient's endotracheal tube does not become kinked
B) Ensuring that the patient's head is positioned to prevent cervical nerve injury
C) Carefully taping the patient's eyes shut to avoid corneal abrasions
D) Padding the operating table carefully and keeping linens free of wrinkles

Question 19

The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient's breath sounds are clear but diminished, shallow, and slightly labored. The patient's pulse oximetry is 96% on room air. What is the priority action of the nurse?

A) Administer a dose of the prescribed pain medication.
B) Administer 2 L of oxygen via nasal cannula.
C) Obtain an order from the physician for a chest x-ray.
D) Ensure that the patient is using the spirometer 10 times every hour.

Question 20

The nurse is caring for a male patient who is having open heart surgery. The patient's chest is covered with thick hair, so the surgical technician begins to shave the patient's skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique?

A) A straight safety razor and antibiotic foam is used.
B) Disposable electric trimmers are used to trim the hair.
C) Antibacterial soap is used prior to hair removal.
D) Only the hair directly around the surgical site is removed.

Question 21

Which patients would benefit from preoperative teaching about splinting of incisions to minimize discomfort?

A) Patient having coronary bypass graft surgery
B) Patient having open breast biopsy
C) Patient having total hip replacement surgery
D) Patient having lumbar spine decompression surgery
E) Patient having surgery to repair retinal detachment
F) Patient having total abdominal hysterectomy

Question 22

The nurse is caring for a patient who underwent abdominal surgery the previous day. Which assessment findings indicate to the nurse that the patient may be experiencing serious internal bleeding?

A) The patient's urinary output increased to 40 mL/hr.
B) The patient's pulse has risen from 76 to 112 beats/min.
C) The patient states that his abdominal pain is worse than yesterday.
D) The patient complains of generalized itching.
E) The patient's hematocrit dropped from 14.6 to 11.0 g/dL.
F) The patient has not been able to have a bowel movement since before surgery.

Question 23

The nurse is working with a nursing assistant to care for several postoperative patients. Which interventions can the nurse delegate to the assistant for completion?

A) Assess patients' comfort levels and need for pain medication.
B) Empty urinary catheter bags and record urine output.
C) Teach patients how to use incentive spirometers hourly.
D) Provide ice chips and juice to patients who are no longer NPO.
E) Monitor incisions for signs of infection.
F) Apply TED hose and assist with oral care.

Question 24

The nurse is caring for a patient who is recovering from bowel resection surgery. Which assessment findings indicate to the nurse that the patient no longer needs to remain NPO and may progress to oral intake of food and fluids?

A) The patient passed flatus while ambulating this morning.
B) The patient's abdomen is soft with active bowel sounds $\times$ 4 quadrants.
C) The patient denies nausea or vomiting and states that he feels hungry.
D) The patient's abdominal incision is clean, dry, and intact with staples.
E) The patient ambulated in the hallway with a slow, steady gait.
F) The patient's urinary catheter is patent with clear, yellow urine.